<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group hide">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_patient_char_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_patient_char_id" data-rule="required" class="form-control selectpage form-control" name="row[presentation_patient_char_id]" type="text" value="{:$_GET['cid']}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version_for_reported_causes_of_death')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version_for_reported_causes_of_death" class="form-control form-control" name="row[meddra_version_for_reported_causes_of_death]" type="number">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reported_causes_of_death_meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reported_causes_of_death_meddra_code"
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   class="form-control  selectpage  form-control" name="row[reported_causes_of_death_meddra_code]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reported_causes_of_death_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-reported_causes_of_death_free_text"
                      class="form-control form-control" name="row[reported_causes_of_death_free_text]"  cols="60" rows="15"></textarea>
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
